Tuesday, March 24, 2009
Stanford resistance mutation sheet
Viral decay curve
http://www.nature.com/nm/journal/v9/n7/fig_tab/nm0703-853_F2.html
from (http://www.nature.com/nm/journal/v9/n7/full/nm0703-853.html)
- Christopher Hurt
Map of Moore Regional
http://www.firsthealth.org/PDF/maps/MRH_internal.pdf
- Christopher Hurt
Monday, August 25, 2008
Super cool HIV interactive graphic
http://content.nejm.org/content/vol359/issue4/images/data/339/DC2/AIDS_Interactive.shtml
Enjoy!
– Christopher Hurt, MD
Monday, August 18, 2008
Sexual Assaults and PEP
Baseline laboratory tests should include:
- HIV Antibody testing
- CBC with differential
- LFTs
- BUN/Creatinine
- STD Screen (gonorrhea, chlamydia, syphilis)
- Hepatitis B serology
- Hepatitis C serology
- Pregnancy test
Prophylaxis against the most frequently diagnosed STDs among sexually assaulted women should be administered:
- Ceftriaxone 125mg IM in a single dose [Gonorrhea]
- Metronidazole 2gms orally in a single dose [BV, Trichomoniasis]
- Azithromycin 1gm orally in a single dose OR Doxycycline 100mg orally twice daily for seven days [Chlamydia]
HIV post-exposure prophylaxis is offered within 72 hours of the assault. If the perpetrator's HIV medical history is unknown, the two preferred regimens are:
- NNRTI-based: Efavirenz plus (Lamivudine or Emtricitabine) plus (Zidovudine or Tenofovir)...usually as Sustiva plus Combivir, or Sustiva plus Truvada.
- PI-based: Lopinavir/Ritonavir (Kaletra), plus Zidovudine or Tenofovir...usually as Kaletra plus Combivir, or Kaletra plus Truvada.
I've been advised typically to use the PI-based regimen unless there is another reason they should be avoided. Keep in mind that if the source patient (in the case of needlesticks) is one of OUR HIV clinic patients, we have access to their genotype and med history, and can formulate an appropriate PEP for the victim based on this information (i.e. you wouldn't want to start someone on PEP that their virus would be resistant to).
All sexual assault cases should follow up with a mid-level provider in the ID Clinic, regardless of whether or not they accept PEP. We usually just send a phone message to Lynda Bell with the patient's general information, and she contacts them to set up a follow up within 48 hours or so.
Risk Assessment
Sometimes, you are asked to comment on the risk, given different exposures (assault, blood splashes in the eye, needlestick, etc.). The risk for HIV acquisition per various acts can be found in the MMWR, January 21, 2005). It is also estimated in the Sanford Guide for the treatment of HIV.
Vaccinations in PEP
Hepatitis B: Patients who are unvaccinated prior to the assault should receive the initial Hep B vaccine, and follow up to complete the series. Unless the offender is known to have Acute Hep B, HBIG is not required. Remember, all patients should have serologies drawn.
Tetanus: If the patient has skin abrasions or other wounds and immunization status is greater than 5 years, give Tetanus Toxoid 0.5ml IM. If the patient has never been immunized, also give Hyper-Tetanus 250mcg IM.
Yvonne Carter, MD
Review of PPDs
>0 mm is considered a positive reaction if the patient:
- Is HIV-positive or immunocompromised AND are recent contacts to known or suspected infectious TB disease, regardless of previous treatment of LTBI
- Is HIV-positive with fibrotic changes on CXR consistent with prior TB who have received inadequate or no treatment for TB disease
- Is a child <5>
>5 mm is considered a positive reaction if the patient:
- Is HIV-positive
- Is a contact to known or suspected infectious TB case identified within the last two years
- Has fibrotic changes on CXR consistent with prior TB and have received inadequate or no treatment for TB disease
- Is Immunocompromised (receiving >15mg per day of Prednisone for one month, other immunosuppressive drugs, organ transplant recipients, persons taking TNF inhibitors)
>10 mm is considered a positive reaction if the patient:
- Is foreign-born from Asia, Africa, Carribean, Latin America, Mexico, South America, Pacific Islands, or Eastern Europe)
- Has converted their TST within two years
- Has a medical condition placing them at high-risk for TB Disease (DM, CRI, Chronic malabsorption syndrome, Leukemias and Lymphomas, Cancer of the head and neck, Silicosis, Weight loss of >10% ideal body weight, gastrectomy or intestinal bypass)
- Is an injection drug or crack cocaine user
- Is a child <4>
- Works in a mycobacterial lab
*Also, this cutoff is used per the clinicians judgement for: residents of long-term care facilities and homeless shelters, are inmates in the DOC, OR are employees in prisons/jails, long-term care facilities, hospitals/health care facilities, adult day-care centers for HIV patients, homeless shelters).
>15 mm is considered a positive reaction if the patient:
- Has NO risk factors for TB
Hope this helps!
Yvonne Carter, MD
HIV, Syphilis, and When to LP
When is it necessary to perform an LP in to rule out Neurosyphilis in the HIV-positive patient?
The answer has many answers, but the commonly accepted answer is as follows: "All neurologically asymptomatic HIV-infected patients whose serum RPR titer is greater than or equal to 1:32 should undergo lumbar puncture regardless of syphilis stage." And, of course, any symptomatic HIV-patient with a history of syphilis should undergo LP to rule out Neurosyphilis.
This recommendation is taken from two main studies:
- Marra, et al. J Infect Dis 2004; 189: 369 - 376.
- Libois, et al. Sex Transm Dis 2006. HIV and syphilis: When to perform a lumbar puncture.
Yvonne Carter, MD